There are certainly many serious problems in healthcare. Let’s look at nursing, in particular. It’s a rewarding job, but it’s far more frustrating for nurses than it needs to be.
Nurses often don’t have enough time in the day (or in a given hour) to do all of their work the right way in the time available. I’ve worked with nurses who listed out all of the tasks they were supposed to do in an hour, from rounding on patients, giving medications, etc. and it added up to 80 minutes worth of work to be done in 60 minutes.
Nurses are often forced into a position of choosing what to cut corners on. What tasks do you skip or delay? Nurses, thankfully, use judgment to determine what tasks are “lowest risk,” for the sake of their patients. They’re also doing so for the sake of their jobs, since they’ll likely get blamed and punished for making an error in a bad system. That’s not Lean thinking of course, but it’s sadly common.
That’s bad for nurses and it’s bad for patients. It must be fixed.
We have overburdened nurses (and staff in other areas). We have low patient satisfaction and quality that’s lower than it should be. Patients’ discharges are being delayed. Too many patients are being harmed and killed due to preventable errors.
Some people say (I think incorrectly) that “Lean is all about waste.”
The Japanese word for waste is “muda.”
I think the bigger problem in healthcare is “muri,” or overburden.
Overburden leads to waste. It leads to stress, harm, and higher costs.
What is the Real Problem?
The problem often gets framed as “we don’t have enough nurses.”
That’s a solution disguised as a problem statement. The solution to “not enough nurses” is, of course, “add more nurses.”
That’s not necessarily affordable. We might not be able to recruit more nurses. And, that’s not the only way to solve the real problem.
When you hear people say “we need more nurses” (solution) or “we don’t have enough nurses” (fake problem statement), we should define the real problem(s).
A better, and more accurate, problem statement might be:
- Patients aren’t getting all of the care they need in a timely manner
- Nurses are overburdened and have too much to do
- Patients are being harmed
- Patients are waiting too long to be discharged
Of course, we would want to get more specific and quantify those problem statements in terms of a “gap” to be closed, but let’s skip that for now.
We can rally everybody around improving patient care. An objective problem solver would only care about solving these important problems.
There are certain groups that seem to advocate primarily for their solution (more nurses). Unions, for example, benefit from more nurses because that means more dues for them. Do the nurses’ unions care about reducing patient harm? Of course. But, some of them seem too stuck on a single solution (more nurses).
What Can We Do About These Problems?
If we’re going to solve one of those problems… and not having enough nurse time is one of the causes (or even a root cause), then there are two main countermeasures we can take:
- Add more nurses
- Reduce waste to free up nurse time
There’s a lot of talk and research about patient:nurse ratios. Studies suggest that a lower patient:nurse ratio results in better care (or having fewer nurses per patient results in worse outcomes). That seems intuitive.
But, I’d propose the number that really matters is the amount of nursing time available in an hour or a day. How much time do nurses get at the bedside?
Before Lean, it’s very common to see that nurses only get about 30% of their time at the bedside with the patient. Increasing this time at the bedside results in better patient care and higher patient satisfaction (and you can see how that would be more rewarding for the patients).
Look at part of this spreadsheet that I created… if we have 24 patients and 4 nurses, that’s a 6:1 ratio.
You can do the math of 4 nurses * 12 hours per shift * 30% bedside time / 24 = 0.6 effective bedside hours per patient per shift
Adding Nurses is One Option
If we add nurses, you can see how the hours per patient increases, but you can also see how cost increases (at a burdened rate of $45/hour):
If we double the number of nurses, we get double the time at the bedside (assuming the 30% ratio stays the same). The cost per year has doubled (the cost of that day shift multiplied by 365).
Even if we’re “throwing nurses at the problem,” we should look and see if increasing staffing levels by about $800,000 would reduce the cost of poor quality and the cost of longer length of stay.
Throwing people at the problem might not be the BEST strategy, but at least it’s a strategy. I’d respect that more than doing nothing and expecting better results.
Reducing Waste through Lean is a Better Option
Lean provides a welcome alternative to just adding nurses. We can reduce waste, which frees up more time for the existing nurses to reapply to patient care.
We can get staff member ideas, through a Kaizen process, to ask them what problems need to be solved to free up their time.
The hospital might run “rapid improvement events” that are focused on making more dramatic changes that would free up time.
We might implement a Kanban system ensures that supplies don’t run out. We might install “nurse servers” to make sure those supplies are as close to the bedside as possible.
Team roles and responsibilities might be reconfigured, as we analyze what nurses, CNAs (techs), and housekeeping staff should be doing. Are nurses doing work that should be done by others (and vice versa).
Technology and software might need to be improved. Better communication systems can be put in place. Important information can be made more visual.
There are many, many improvements that can be made that free up nurse time. Virginia Mason Medical Center has increased nursing time at the bedside to 90%.
What happens when we keep staffing levels and the same and increase time at the bedside? The baseline is on the top row:
If we can take bedside time from 30% to 60% (in my experience that’s very achievable), we can get the same effective hours per patient (1.2) without doubling labor cost.
If we can reach Virginia Mason levels, we TRIPLE nursing time, without adding cost.
Or, if we add one nurse AND increase the percent time at the bedside to 60%, we do even better (1.5 hours per patient).
And here is a chart the summarizes the effect of adding more nurses and/or increasing the percentage of time at the bedside.
What are your thoughts on this? What are you doing to free up nursing time using Lean or other methods?
Can we convince people that Lean is not just an alternative to layoffs, but is also an alternative to throwing people at a problem?
About LeanBlog.org: Mark Graban is a consultant, author, and speaker in the “lean healthcare” methodology. Mark is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. Mark is also the VP of Customer Success for the technology company KaiNexus. He lives in San Antonio, Texas.